Which term describes an assessment performed by the physician to document exam findings, both positive and negative?

• A. Disposition
• B. Attestation
• C. Medical Record
• D. Physical Examination

Answer: (D)

Physical examination is the hands-on assessment the physician performs to document what is found during the exam, including both positive findings (abnormal signs) and negative findings (normal findings). This thorough recording ensures a complete picture of the patient’s current status and helps guide diagnosis and treatment. The other terms refer to different things: disposition is about where the patient goes after care, attestation is a formal statement of verification, and medical record is the overall chart that holds all notes. The physical examination specifically describes the clinician’s assessment and the documentation of what’s observed, whether present or absent.